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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157201395
Report Date: 11/15/2022
Date Signed: 11/15/2022 12:51:47 PM

Document Has Been Signed on 11/15/2022 12:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:CNS ALTA PEAKFACILITY NUMBER:
157201395
ADMINISTRATOR:GRIGSBY, DIEDRAFACILITY TYPE:
735
ADDRESS:7510 ALTA PEAKTELEPHONE:
(661) 665-9980
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY: 5CENSUS: 0DATE:
11/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:04 PM
MET WITH:Diedra Grigsby, AdministratorTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Lady Cabrera arrived unannounced for an Annual Required Inspection. LPA met with Administrator Diedra Grigsby. LPA stated the purpose of the visit. Administrator reported there are no clients and no staff at the facility at this time. A tour of the facility was conducted. Facility has one entrance/exit point.

Facility appeared clean with no obstruction or fire clearance issues. Hand sanitizer was readily available. Kitchen and Bathrooms have trashcans with lid. Hand washing posters were observed by the bathrooms. Bedrooms were checked. The exterior tour was conducted.

Cleaning and PPE supplies were checked. Administrator was observed with mask on.


Exit interview was conducted.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: CNS ALTA PEAK
FACILITY NUMBER: 157201395
VISIT DATE: 11/15/2022
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Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Adult Residential Facility (ARF):


· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan For Adult Residential Facilities
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Administrator Certificate


Please submit the above forms/information to Fresno CCL by: 11/22/2022

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2